Site Safety And Health Plan ICS-208-CG (rev 4/15)

1. Incident NamePROTECTIVE EQUIPMENT5. Supervisor/Leader6. Location and Size of Site2. Date/Time PreparedCG ICS SSP: PERSONAL3. Operational Period7. Hazards Addressed:9. Equipment:11. Inspection Procedures:15. Prepared By:4. Safety Officer (include method ofcontact):8. For Emergencies Contact:10. References Consulted:12. Donning Procedures:16. Date/Time Briefed:13. Doffing Procedures:14. Limitations and Precautions (includemaximum stay time in PPE):Potential Health Effects: Bruise/Lacerations, Organ Damage, CentralNervous System Effects, Cancer, Reproductive Damage, Low BackPain, Temporary Hearing Loss, Dermatitis, Respiratory Effects, BoneBreaks, Eye BurningICS-208-CG SSP-F:(Rev 4/15)Pageof

CG ICS SSP:DECONTAMINATION5. Supervisor/Leader1. Incident Name6. Location and Size of Site2. Date/Time Prepared7. For Emergencies Contact:9. Equipment:4. Safety Officer (include method ofcontact):8. Hazard(s) Addressed:10. References Consulted:11. Contamination Avoidance Practices:14. Prepared By:3. Operational Period12. Decon Diagram:15. Date/Time Briefed:Attached,Drawn belowPotential Health Effects: Bruise/Lacerations, Organ Damage, CentralNervous System Effects, Cancer, Reproductive Damage, Low BackPain, Temporary Hearing Loss, Dermatitis, Respiratory Effects, BoneBreaks, Eye Burning13. Decon StepsICS-208-CG SSP-G(rev 4/15):Pageof

CG ICS SSP:ENFORCEMENT LOG1. Incident Name2. Date/Time Prepared3. Operational Period4. Safety Officer (include method of contact)5. Supervisor/Leader6. For Emergencies Contact:7. Attachments:8.a. Job Task/Activity8.b. Hazards8.c. Deficiency9. Prepared By:10. Date/Time Briefed:HAZARD LIST: Physical/Safety, Toxic, Explosion/Fire, OxygenDeficiency, Ionizing Radiation, Biological, Biomedical, Electrical, HeatStress, Cold Stress, Ergonomic, Noise, Cancer, Dermatitis, Drowning,Fatigue, Vehicle, & Diving8.d. Action Taken8.e. Safety PlanAmended?8.f. Signature ofSupervisor/LeaderICS-208-CG SSP-H(rev 4/15):Pageof

CG ICS SSP WORKERACKNOWLEDGEMENT FORM1. Incident Name2. Site Location:4. Type of BriefingSafety Plan/Emergency Response PlanStart ShiftPre-EntryExitEnd of ShiftSpecify Other:5. Presented By:6. Date Presented7. Time Presented8.a. Worker Name (Print)8.b. Signature*8.c. Date8.d. Time* By signing this document, I am stating that I have read and fully understandthe plan and/or information provided to me.3. Attachments:ICS-208-CG SSP-I (rev 4/15): Worker AcknowledgementPageof

CG ICS SSP: EmergencySafety & Response Plan1910.120 ComplianceChecklist (Form A)6.a. Cite: i)(vii)(viii)(ix)1. Incident Name2. Date/Time Prepared3. OperationalPeriod6.b. Requirement(sections that duplicate or explain are omitted)6.c. ICS FormIs the plan in writing?Is the plan available for inspection by employees?Does the plan address pre-emergency planning and coordination?Does it address personnel roles?Does it address lines of authority?Does it address communications?Does it address emergency recognition?Does it address emergency prevention?Does it identify safe distances?Does it address places of refuge?Does it address site security and control?Does it identify evacuation routes?Does it identify evacuation procedures?Does it address decontamination?Does it address medical treatment and first aid?Does it address emergency alerting procedures?Does it address emergency response proceduresWas the response critiqued?Does it identify Personal Protection Equipment?Does it identify emergency equipment?All the hazardous substances identified to the extent possible?All the hazardous conditions identified to the extent possible?Was site analysis addressed?Were engineering controls addressed?Were exposure limits addressed?Were hazardous substance handling procedures addressed?Is the PPE appropriate for the hazards identified?Is respiratory protection worn when inhalation hazards present?Is the buddy system used in the hazard zone?Are backup personnel on standby?Are advanced first aid support personnel standing by?Has the ICS designated safety official been identified?Has the Safety Official evaluated the hazards?Can the Safety Official communicate with IC immediately?Are appropriate decontamination procedures /AN/A4. Site Supervisor/Leader6.d. Check5. Location of Site6.e. CommentsPerformance basedPerformance basedPerformance basedPerformance basedPerformance basedPerformance basedPerformance basedPerformance basedPerformance basedPerformance basedPerformance basedPerformance basedPerformance basedPerformance basedPerformance basedPerformance basedICS-208-CG SSP-J (rev 4/15) Pageof

CG ICS SSP: 1910.120COMPLIANCE CHECKLIST(Form B)6.a. Cite: 1910.1201910.120 ii)(iv)(v)(vi)(vii)(c)(5)(i)(iv)(ii)(iii)1. Incident Name2. Date/Time Prepared6.b. Requirement(sections that duplicate or explain are omitted)Organizational structure?Comprehensive workplan?Site Safety Plan?Safety and health training program?Medical surveillance program?Employer SOPs?Written program related to site activities?Site excavation meets shored or slope requirements in 1926?Lines of communication?Training addressed?Information and medical monitoring addressed?Site Safety Plan kept on site?Safety and health hazard analysis conducted?Properly trained employees assigned to right jobs?Personnel Protective Equipment issues addressed?Frequency and types of air monitoring addressed?Site control measures in place?Decontamination procedures in place?Emergency Response Plan in place?Confined space entry procedures?Spill containment programPre-entry briefings conducted?Site Safety Plan effectiveness evaluated?Site characterization done?Preliminary evaluation done by qualified person?Hazard identification performed?Location and size of site identified?Response activities, job tasks identified?Duration of tasks identified?Site topography and accessibility addressed?Health and safety hazards addressed?Dispersion pathways addressed?Status and capabilities of medical emergency response teams?Chemical protective clothing addressed and properly selected?Respiratory protection addressed?Level B used for unknowns?3. OperationalPeriod6.c. ICS Form203IAPSSP-BN/AN/AN/AN/AN/A201 203 SP-B206SSP-FSSP-B and FN/A4. Site Supervisor/Leader6.d. Check5. Location of Site6.e. CommentsIncident Action PlanResponsibility of each employerResponsibility of each employerResponsibility of each employerResponsibility of each employerResponsibility of each employerOperational periodICS-208-CG SSP-K (rev 4/15): Page 1. Pageof

CG ICS SSP: 1910.120COMPLIANCE CHECKLIST(Form B)6.a. Cite: 1910.1201910.120 ii)(ix)(h) k)(8)(l)(1)(iii)(iv)(v)(vi)(vii)(ix)(x)(xi)1. Incident Name2. Date/Time Prepared6.b. Requirement(sections that duplicate or explain are omitted)Monitoring for ionization conducted?Monitoring conducted for IDLH conditions?Personnel looking out for dangers of IDLH environments?Ongoing air monitoring program in place?Employees informed of potential hazard occurrence?Properties of each chemical made aware to employees?Appropriate site control procedures in place?Site control program developed during planning stages?Site map, work zones, alarms, communications addressed?Engineering, admin controls considered?Personnel not rotated to reduce exposures?PPE selection criteria part of employer’s program?PPE use and limitations identified?Work mission duration identified?PPE properly maintained and stored?Are employees properly trained and fitted with PPE?Are donning and doffing procedures identified?Are inspection procedures properly identified?Is a PPE evaluation program in place?Periodic monitoring conducted?Have decontamination procedures been established?Are procedures in place for contamination avoidance?Is personal clothing properly deconned prior to leaving the site?Are decontamination deficiencies identified and corrected?Are decontamination lines in the proper location?Are solutions/equipment used in decon properly disposed of?Is protective clothing and equipment properly secured?If cleaning facilities are used, are they aware of the hazards?Have showers and change rooms provided, if necessary?Are provisions for reporting emergencies identified?Are safe distances and places of refuge identified?Site security and control addressed in emergencies?Evacuation routes and procedures identified?Emergency decontamination procedures developed?Emergency alerting and response procedures identified?Response teams critiqued and followup performed?Emergency PPE and equipment available?6.c. ICS FormSSP-ESSP-EN/ASSP-ESSP-BSSP-BIAP, SSP-BIAP, SSP-BIAP, -ESSP-GSSP-GSSP-GSSP-HSSP-CN/AN/AN/AN/ASSP-DSSP-B and CSSP-DSSP-DSSP-DSSP-DSSP-HSSP-D3. Operational Period6.d. Check6.e. CommentsResponsibility of employerResponsibility of employerResponsibility of employerICS-208-CG SSP-K (rev 4/15): Page 2. Pageof

CG ICS SSP: 1910.120COMPLIANCE CHECKLIST(Form B)6.a. Cite:2. Date/Time Prepared6.b. Requirement(sections that duplicate or explain are omitted)1910.120 (l)(3)(i)(ii)(iii)(iv)(v)1910.165 (7)7. Prepared By:1. Incident NameEmergency notification procedures identified?Emergency response plan separate from Site Safety Plan?Emergency response plan compatible with other plans?Emergency response plan rehearsed regularly?Emergency response plan maintained and kept current?Can alarms be seen/heard above ambient light and noiselevels?Are alarms distinct and recognizable?Are employees aware of the alarms and are they accessible?Are emergency phone numbers, radio frequencies clearlyposted?Signaling devices in place where there are 10 or more workers?Are alarms like steam whistles, air horns being used?Are backup alarms available?Are areas adequately illuminated?Is an adequate supply of potable water available?Are drinking water containers equipped with a tap?Are drinking water containers clearly marked?Is a drinking cup receptacle available and clearly marked?Are non-potable water containers clearly marked?Are their sufficient toilets available?Have food handling issues been addressed?Have adequate wash facilities been provided outside hazardzone?If response is greater than 6 months, have showers beenprovided?6.c. ICSFormSSP-DSSP-DSSP-DSSP-DSSP-HN/A3. Operational Period6.d. Check6.e. APIAPIAPICS-208-CG SSP-K (rev 4/15): Page 3.Pageof

CG ICS SSP: 1910.120DRUM COMPLIANCECHECKSHEET1. Incident Name2. Date/Time Prepared5. Supervisor/Leader6. Location and Size of Site7. For Emergencies Contact:3. Operational Period4. Safety Officer (include method ofcontact):8. Note: tanks and vaults should also be treated in thesame manner as described below [1910.120(j)(9)].Many can also pose confined space hazards.9.a. Cite: 1910.120 (Citesthat duplicate or explainrequirements are )(8)(ii-iii)(iv)10. Prepared By:9.b. Requirement9.c. Check9.d. CommentsDrums meet DOT, OSHA, EPA regs for waste they contain, including shipment?Drums inspected and integrity ensured prior to movement?Or drums moved to an accessible location (staging area) prior to movement?Unlabelled drums treated as unknown until properly identified and labeled?Site activities organized to minimize drum handling?Employers properly warned about the hazards of moving and handling drums?Suitable overpack drums are available for addressing leaking and ruptured drums?Leaking materials from drums properly contained?Are drums that cannot be moved, emptied of contents with transfer equipment?Are suspect buried drums surveyed with underground detection system?Are soil and covering material above buried drums removed with caution?Is the proper extinguishing equipment on scene to control incipient fires?Are airlines on supplied air systems protected from leaking drums?Are employees at a safe distance, using remote equipment, when handling explosive drums?Are explosive shields in plane to protect workers opening explosive drums?Is response equipment positioned behind shields when shields are used?Are non-sparking tools used in flammable or potentially flammable atmospheres?Are drums under extreme pressure opened slowly & workers protected by shields/distance?Are workers prohibited from standing and working on drums?Is the drum handling equipment positioned and operated to minimize sources of ignition?For shock sensitive drums, have all non-essential employees been evacuated?For shock sensitive drums: is handling equipment provided with shields to protect workers?Are alarms that announce start/finish of explosive drum handling actions in place?Are continuous communications in place between the drum handling site & command post?Are drums under pressure properly controlled for prior to handling?Are drums containing packaged laboratory wastes treated as shock sensitive?Are lab packs opened by trained and experienced personnel?Are lab packs showing crystallization treated as shock sensitive?Are drum staging areas manageable with marked access and egress?Is bulking of drums conducted only after drum contents have been properly identified?Form SSP-L (rev 4/15) Pageof

Site Safety and Health Plan ICS-208-CG (rev 4/15) Incident Name: Date/Time Prepared: Operational Period: Purpose. The ICS Compatible Site Safety and Health Plan is designed for safety and health personnel that use the Incident Command System (ICS). It is compatible with ICS and is intended to meet the requirements of the Hazardous Waste .